MAUDE Adverse Event Report: SISTEMAS MEDICOS ALARIS S.A. DE C.V. BD MAXZERO EXTENSION SET; INTRAVASCULAR ADMINISTRATION SET

Catalog Number	MZX5305
Medical Device Problem Code	Material Separation (1562)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	02/02/2024
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported that bd maxzero extension set separated the following information was received by the initial reporter with the following verbatim: reported issue: iv inserted and attempting lab draw.Upon attaching extension tubing to angiocath hub and drawing of blood through extension tubing the blue pressure cap came off tubing causing blood to pour out of remaining tubing.Pressure applied above iv site and nurse assist button activated.Second rn came to bedside to assist by gathering new supplies to prevent needing to remove angiocath and start new iv.
Additional Manufacturer Narrative
H.3.If a device evaluation and/or device history review is completed, a supplemental report will be filed.
Additional Manufacturer Narrative
It was reported by customer that iv inserted and attempting lab draw.Upon attaching extension tubing to angiocath hub and drawing of blood through extension tubing the blue pressure cap came off tubing causing blood to pour out of remaining tubing.No product or photo was returned by the customer.The customer complaint of separation other component could not be verified due to the product not being returned for failure investigation.Due to no sample being received, an investigation could not be performed and a root cause could not be determined.A device history record review for model mzx5305 lot number 23109324 was performed.The search showed that a total of (b)(4) units in 1 lot number was built on 25oct2023.There were no quality notifications issued for the failure mode reported by the customer during the production build of this set.This incident has been added to our database of reported incidents.Our business team regularly reviews the collected data for identification of emerging trends.
Event or Problem Description
No additional information was provided.Material #: mzx5305, batch#: 23109324.It was reported by customer that iv inserted and attempting lab draw.Upon attaching extension tubing to angiocath hub and drawing of blood through extension tubing the blue pressure cap came off tubing causing blood to pour out of remaining tubing.Pressure applied above iv site and nurse assist button activated.Second rn came to bedside to assist by gathering new supplies to prevent needing to remove angiocath and start new iv.Verbatim: rcc received a complaint via email.Email(s) attached.Injuries or adverse event: no.Item: mzx5305.Quantity affected: (b)(4).Serial/lot number: (b)(6).Po : (b)(6).Are any samples available for return? yes.Reported issue: iv inserted and attempting lab draw.Upon attaching extension tubing to angiocath hub and drawing of blood through extension tubing the blue pressure cap came off tubing causing blood to pour out of remaining tubing.Pressure applied above iv site and nurse assist button activated.Second rn came to bedside to assist by gathering new supplies to prevent needing to remove angiocath and start new iv.

• Brand Name: BD MAXZERO EXTENSION SET
• Common Device Name: INTRAVASCULAR ADMINISTRATION SET
• Manufacturer (Section D): SISTEMAS MEDICOS ALARIS S.A. DE C.V.; blvd. insurgentes no. 20351; parque industrial el florido; tijuana
• Manufacturer (Section G): SISTEMAS MEDICOS ALARIS S.A. DE C.V.; blvd. insurgentes no. 20351; parque industrial el florido; tijuana
• Manufacturer Contact: helen cox (mdr) ; 75 north fairway drive; vernon hills, IL 60061 ; 8473935694
• MDR Report Key: 18775459
• Report Number: 9616066-2024-00298
• Device Sequence Number: 6309678
• Product Code: FPA
• UDI-Device Identifier: 10885403463785
• UDI-Public: (01)10885403463785
• Combination Product (Y/N): N
• Initial Reporter State: OR
• Initial Reporter Country: US
• PMA/510(K) Number: K171957
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: User Facility
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 04/22/2024

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Operator of Device: Other
• Device Catalogue Number: MZX5305
• Device Lot Number: 23109324
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 02/02/2024
• Supplement Date Received by Manufacturer: 04/22/2024
• Initial Report FDA Received Date: 02/26/2024
• Supplement Report FDA Received Date: 05/15/2024
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 10/25/2023
• Is the Device Labeled for Single Use? (Y/N): Yes
• Usage of Device: Initial
• Patient Sequence Number: 1
• Patient Sex: Unknown